Access to Health Care for Transgender Patients: An Overview

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Access to Health Care for Transgender
PatientsAn Overview

• PAETC Training for Trainers
• April 14-16, 2003

Samuel Lurie www.tgtrain.org
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Training Study Findings

• 2001-2002 Needs Assessment of Health Care
  Providers showedFace-to-face key informant
  interviews with providers around New England,
  funded with support of New England AIDS Education
  and Training Center
• Experience with a range of transgendered
  expressions but lack of information on
  populations, terminology, differences
• Desire to treat TG patients respectfully but
  admitted discomfort and lack of tools for
  specific interviewing/assessments.
• Concern and frustration with lack of information,
  studies and research
• Concern and frustration with lack of treatment
  guidelines, referral contacts and ways to
  advocate for transgender clients.
• Time constraints create an overarching barrier in
  building trusting relationships with clients, and
  trusting relationships are integral to quality
  care

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Four Steps to Providing Care

1. Understand range of gender expressions and
   differences in desire for and access to surgical
   or hormonal interventions.
2. Recognize distinctions between gender identity
   and sexual orientation and understand differences
   (and similarities) in health care delivery needs.
3. Understand access to care is affected by negative
   experiences with providers and role providers can
   play in improving quality of life for trans
   people.
4. Making agencies more trans-friendly

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Recognize Range of Expressions and Desires

• Many words to identify gender-variance,
  including
• MTF, FTM, transman, transwoman, bi-gendered,
  gender-blender, phallic woman, passing man,
  she-male, femme queen, non-op, boi, two-spirit,
  new man, new woman, etc.
• Terms
• Transgender vs. Transexual
• FTM, Transman
• MTF, Transwoman
• Pre-op, post-op, non-op
• Intersex
• Transition, SOFFA

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Range of Expressions, cont

• Identities can and do change, based on context,
  culture, geography, and individuals place on
  their life journey
• Hormones and surgical interventions may be
  desired in an order or degree other than what
  protocols dictate.
• Watch for pathologizing/medicalizing situation
  (even words like pre-op and post-op assume
  op as final outcome. Also, emphasis is on
  genitals, not person.)

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Gender identity and sexual orientation are
different things

• Every individual has a biological sex, a gender
  identity and a sexual orientation.
• All can be considered fluid.
• But being transgendered does not mean youre gay
  and being gay does not mean youre transgendered.
  
• There is overlap, in part because gender variance
  is often seen in gay context.
• Masculine females and feminine males are
  assumedto be gay
• anti-gay discrimination and violence often
  targets gender expression, not sexuality

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Traditional Binary Gender Model

• Biological Sex Male FemaleHormones,
  genitaliasecondary sex characteristics
• Gender Expression Masculine FeminineDress,
  posture, roles, identity
• Sexual Orientation Attracted Attracted
  to Women to Men

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Revolutionary Gender Model

• Biological Sex Male Intersexed FemaleHormones,
  genitaliasecondary sex characteristics
• Gender Expression Masculine Androgynous
  FeminineDress, posture, roles, identity
• Sexual Orientation Attracted to
  women men both neither other

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Revolutionary Gender ModelMany configurations
are possible

• Biological Sex Male Intersexed FemaleHormones,
  genitaliasecondary sex characteristics
• Gender Expression Masculine Androgynous
  FeminineDress, posture, roles, identity
• Sexual Orientation Attracted to
  women men both neither other

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Revolutionary Gender ModelMany configurations
are possible

• Biological Sex Male Intersexed
  FemaleHormones, genitaliasecondary sex
  characteristics
• Gender Identity Man Bi-gendered Woman
• I am a
• Gender Expression Masculine Androgynous
  FeminineDress, posture, roles, identity
• Sexual Orientation Attracted to
  women men both other

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Reminders

• Homophobia is different than Transphobia
• Trans people are often outcast in G/L context.
• Pfc. Barry Winchell

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Calpernia Adams Photos from her website at
www.calpernia.com
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Risks and Need

• Not many studies, but all show painfully high
  rates of HIV infection.
• From 22 in recent LA Study to 68 in 1993 study
  in Atlanta.
• 35 in SF MTFs 63 African-American MTFs
  (Clements-Nolle, Am. Journal of Public Health,
  June 2001)
• Often people dont know they are infected, or
  have no access to care.
• In SF study, 50 of those who knew status, not
  receiving care.
• CDC places TG people in MSM category for funding
  and prevention programs.

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Barriers to Care and Treatment

• Providers lack basic knowledge and have
  discomfort
• Lack of research and information
• Topic still derided by other professionals
• Not enough people doing the work
• Extensive negative experiences with health care
• Medicalization and Pathologizing of
  Experience-judgmental, patronizing and
  humiliating treatment
• In-take forms, office environment, alienating
  process
• Insurance issues and long waiting lists
• Workers and agencies come from a deficit
  perspective

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Trans Losses

• Tyra
• Hunter

Billy Tipton
Robert Eads
Alexander John Goodrum
Photo by Mariette Pathy Allen
Photos from Remembering Our Dead,
www.gender.org/remember And Transsexual,
Transgender and Intersexed History,
www.transhistory.org
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Agency-related issues to provide services

• Dont just add T without doing work to
  understand what it means
• Train all staff--receptionists, security guards,
  director
• Make in-take forms trans friendly, i.e. include
  chosen name not just legal name include more
  than M/F
• Respect confidentiality, choices and fluidity
• Honor presenting gender and self-diagnosis
• Challenge transphobiain staff and community
• Have Unisex bathrooms!

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Dr. Lori Kohlers summary

• All trans people are medically underserved
• Hormone treatment is not optional
• Providers who treat HIV disease have unique
  opportunity to improve medical care for trans
  people
• While there are many unanswered questions about
  long-term effects, benefits outweigh the risks
  for most patients.

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Joy

• Working with someone going through a gender
  transition is a joyous part of medicine. Its
  very similar to feelings obstetricians have
  about facilitating birth.
• -Edward Cheslow, MD

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Resources

• Protocols for Hormonal Reassignment of Gender
  from the Tom Waddell Health Center, 2001,
  http//hivinsite.ucsf.edu/InSite.jsp?doc2098.3d5a
  .
• Harry Benjamin International Gender Dysphoria
  Association (February 20, 2001). Standards of
  Care for Gender Identity Disorders, Sixth
  Version. http//www.hbigda.org/socv6.html
• Oriel, K. A. (2000). Medical care of transsexual
  patients. Journal of the Gay and Lesbian Medical
  Association 4(4) 185-193
• Post, P, (2002), Crossing to Safety Transgender
  Health and Homelessness, Healing Hands A
  publication of the Health Care for the Homeless
  Clinicians Network, 6 (4), June 2002.
  http//www.nhchc.org/Network/HealingHands/2002/Jun
  e2002HealingHands.pdf
• Bockting, W and Kirk S, editors, Transgender and
  HIV Risks, prevention and care. Bringhamton, NY
  The Haworth Press (2001) Originally published as
  a special issue of International Journal of
  Trangenderism 3.12. Available online at
  http//www.symposion/ijt

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Resources continued

• Clements-Nolle, K., Marx, R., Guzman, R., Katz,
  M. (2001, June). HIV prevalence, risk behaviors,
  health care use, and mental health status of
  transgender persons implications for public
  health intervention. American Journal of Public
  Health, 91(6), 915-921.
• Keatley, J and Clements-Nolle, K. Factsheet What
  are the Prevention Needs of Male-to-Female
  Transgender Persons? University of California,
  San Francisco, Center for AIDS Prevention
  Studies, (2001) (English and Spanish versions)
  www.caps.ucsf.edu
• Gender Identity 101 A Transgender Primerby
  Alexander John Goodrum, a publication of TGNet
  Arizona, www.tgnetarizona.org
• Intersexed Society of North America
  www.isna.org, Advocacy and educational
  organization founded and led by intersexed
  people.
• For a copy of the Needs Assessment Identifying
  Training Needs of Health Care Providers Related
  to Treatment and Care of Transgendered PatientsA
  Qualitative Needs Assessment contact the author,
  Samuel Lurie, at slurie_at_gmavt.net